New Heights Hospice Inc.

“Upon patient record review, 7 of 14 (Patient #2,3,4,5,6,8,13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: The patient states he has been taking Ensure, Billberry and B12 for a long time. The supplements were not included on the medication profile. Corrected on site. Patient 3: The medication profile has oxygen orders. The patient does not have oxygen and has never used oxygen. Corrected on site. Patient 4,5,8: The POC contains an order for oxygen. This was not included on the medication profile. Corrected on site. Patient 6: The POC contains an order for oxygen. This was not included on the medication profile. The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 13: The POC contains an order for oxygen. This was not included on the medication profile”

“Upon patient record review 9 of 14 (Patients 1,2,3,4,5,6,7,8,10), there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient 1: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meetings on 1/10/25, 1/24/25, 2/7/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 2: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 2/7/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 3: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 1/17/25, 1/31/25, 2/7/25, 2/14/25, 2/7/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 4: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 1/17/25, 1/31/25, 2/7/25, 2/14/25, 2/7/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 5: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on1/17/25, 1/31/25, 2/7/25, 2/14/25, 2/7/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 6: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 11/1/24,11/15/24, 1/17/25, 1/31/25, 2/7/25, 2/14/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 7: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 1/17/25, 1/31/25, 2/7/25, 2/14/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 8: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 2/7/25, 1/24/25, 1/10/25. There is no documentation to support the MSW or SC provided any participation in the IDT. Patient 10: The IDT meetings in the medical record contain evidence of just the MD and the RN being present for the IDT meeting on 10/4/24. There is no documentation to support the MSW or SC provided any participation in the IDT.”

“Upon patient record review, 4 of 14 (Patient #3,5,6,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The patient is on ASA therapy. There is no evidence of a bleeding precaution care plan with goals and interventions on the POC. Patient 5: The SN documented that patient is having difficulty with elevated blood sugars. There is no endocrine care plan with goals and interventions on the POC. Patient 6: The POC contains an order for mechanical soft diet, the CTI by the medical director indicated patient is a high aspiration risk. There was no care plan initiated for high risk for aspiration with goals and interventions on the POC. Patient 10: The SN documented in the comprehensive assessment 10/3/24 “patient is on a mechanical soft diet and has not had any complaints of aspiration”. There was no risk for aspiration care plan added with goals and interventions to the POC.”

“Upon patient record review, 4 of 14 (Patient #4,5,6,8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: The POC 6/12/24 contains an order for Oxygen 2-4 liters per minute PRN. There is no route. Corrected on site. Patient 5: The POC 9/12/24 contains Oxygen 2-4 liters per minute PRN with no route. Corrected on site. Patient 6: The POC 10/30/24 contains Oxygen 2-4 liters per minute PRN with no route and Miralax with no diluent. Corrected on site. Patient 8: The POC 11/18/24 contains Oxygen 2-4 liters per minute PRN with no route. Corrected on site.”

“Upon patient record review, 5 of 14 (Patient #4,6,7,8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The POC contains orders for SN 1-2 times per week. The week of 2/9/25-2/15/25 there was no evidence the SN made any visits. There was no missed visit documentation or evidence of a refusal. Patient 6: There is evidence the patient accepted the SC at recert on 1/28/25. There was an order for SC 1 time per month beginning 1/28/25, there was no visit made to the patient in January by the SC and no evidence of refusal. Patient 7: The SN documented on 2/13/25 “educated to apply pressure bandages as tolerated”. There is no evidence of an order for pressure bandages. Patient 8: The medical record states SC made a visit to the patient on 2/8/25. There is no evidence of an order for SC. Patient 10: The POC 9/29/24 contains an order for PT eval. There is not evidence this was ever completed and no evidence of a refusal or order to cancel the eval.”

“Upon observation and home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: The SN placed the nursing bag on a chair on top of clothing and a box of gloves with no barrier. Per bag policy 6-013.1 the bag is to be placed on a clean surface or a barrier used. Patient 2: The SN placed the nursing bag on a cloth chair with out a barrier. Per bag policy 6-013.1 the bag is to be placed on a clean surface or a barrier used.”

“Upon patient record review 1 of 14 (Patient #4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 4: There is evidence of a supervisory visit made by the RN on 12/12/24 and then there is no supervisory visit made again until 1/23/25.”

“Upon patient record review, 5 of 14 (Patient #1,4,5,8,11) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1; The SN documented “PCG” on 1/14/25, this is not an approved abbreviation. The aide signed their documentation with out any credentials on 2/4/25, 2/14/25. Patient 4: The LVN documented on 2/8/25 “continues to have ulcer to right buttocks and coccyx with daily treatment”. There is no other documentation in the medical record of the pt having a wound. The RN was out the week prior to do a recert and there was no documentation of a wound and no further documentation of a wound after 2/8/25. The RN went out that evening to assess pt and stated the pt does not and did not have a wound. Patient 5: The Aide signed the medical record with out credentials on 1/7/25,1/12/25, 1/16/25. Patient 8: The aide signed the medical record with out credentials on 1/20/25, 1/27/25, 2/3/25, 2/10/25. Patient 11: The SN documented using the following unapproved abbreviations on 2/6/25: TOD and PCG.”